
<div id="messages_product_view"><?php echo $this->getMessagesBlock()->getGroupedHtml() ?></div>
<div class="page-title">
    <h1><?php echo Mage::helper('paymentmail')->__('MoneyGram Form') ?></h1>
</div>
<form action="<?php echo $this->getFormAction(); ?>" id="paymentmailForm" method="post" enctype="multipart/form-data">
    <div class="fieldset">
        <h2 class="legend">
Please fill in the form below after you've made the transfer:
       </h2>
      
        <ul class="form-list">
            <li class="wide">
                    <label for="login_email" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Login Email') ?></label>
                    <div class="input-box">
                        <input name="login_email" id="login_email" title="<?php echo Mage::helper('paymentmail')->__('Login Email') ?>" value="" class="input-text required-entry validate-email" type="text" />
                    </div>
            </li>
           <li class="fields">
               <div class="field">
                    <label for="order_no" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Order No') ?></label>
                    <div class="input-box">
                        <input name="order_no" id="order_no" title="<?php echo Mage::helper('paymentmail')->__('Order No') ?>" value="" class="input-text required-entry validate-number" type="text" />
                    </div>
                </div>
                <div class="field">
                    <label for="mtcn_no" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Money Gram Card No') ?></label>
                    <div class="input-box">
                        <input name="mtcn_no" id="mtcn_no" title="<?php echo Mage::helper('paymentmail')->__('Money Gram Card No') ?>" value="" class="input-text required-entry" type="text" />
                    </div>
                </div>
           </li>
           <li class="fields">
                <div class="field">
                    <label for="firstname" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Sender First Name') ?></label>
                    <div class="input-box">
                        <input name="firstname" id="firstname" title="<?php echo Mage::helper('paymentmail')->__('Sender First Name') ?>" value="" class="input-text required-entry" type="text" />
                    </div>
                </div>
                <div class="field">
                    <label for="lastname" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Sender Last Name') ?></label>
                    <div class="input-box">
                        <input name="lastname" id="lastname" title="<?php echo Mage::helper('paymentmail')->__('Sender Last Name') ?>" value="" class="input-text required-entry " type="text" />
                    </div>
                </div>
            </li>
         <li class="fields">
               
              <div class="field">
                    <label for="country" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Sender Country') ?></label>
                    <div class="input-box">
                       <?php echo $this->getCountryHtmlSelect()?> 
                    </div>
                </div>  
              <div class="field">
                    <label for="sent_amount" class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Sent Amount') ?></label>
                    <div class="input-box">
                        <input name="sent_amount" id="sent_amount" title="<?php echo Mage::helper('paymentmail')->__('Sent Amount') ?>" value="" class="input-text required-entry" type="text" />
                    </div>
                </div>
                
            </li>
            
            <li class="wide">
                <label  class="required"><em>*</em><?php echo Mage::helper('paymentmail')->__('Please Upload Bank Slip Here') ?></label>
             <div class="input-box">
<div style="border: 1px solid #999999; background-color: #eeeeee; padding: 7px;">

    <div>
        <input type="radio" onclick="$('box_local_35dfa584fdb1136992ddb7b14a8d5ffa').show();$('box_url_35dfa584fdb1136992ddb7b14a8d5ffa').hide();" value="local" name="type_fb_file" id="local_35dfa584fdb1136992ddb7b14a8d5ffa" checked="checked" class="radio validate-one-required valign" /><label for="local_35dfa584fdb1136992ddb7b14a8d5ffa" style="float: none;" class="valign">&nbsp;Local</label><br/>
     <input type="radio" onclick="$('box_local_35dfa584fdb1136992ddb7b14a8d5ffa').hide();$('box_url_35dfa584fdb1136992ddb7b14a8d5ffa').show();" value="url" name="type_fb_file" id="url_35dfa584fdb1136992ddb7b14a8d5ffa" class="radio validate-one-required valign" /><label for="url_35dfa584fdb1136992ddb7b14a8d5ffa" style="float: none;" class="valign">&nbsp;URL</label>
    </div>
        <div style="height: 40px;" >
         <input style="width:146px" id="box_local_35dfa584fdb1136992ddb7b14a8d5ffa" type="file" class="input-text required-file" size="12" name="file" />
         <input style="width:146px;display: none;" type="text" class="input-text validate-url" id="box_url_35dfa584fdb1136992ddb7b14a8d5ffa"  value="http://" size="10" name="url" />
        </div>
         </div>
      </div>
                
            </li>
         <li class="additional-row">
             <div><h4>If you have filled out a test question and answer for us in order to retrieve the money, please fill it in below, else please leave it blank</h4></div>  
             <div class="field">
                    <label for="test_question"><?php echo Mage::helper('paymentmail')->__('Test Question') ?></label>
                    <div class="input-box">
                        <input name="test_question" id="test_question" title="<?php echo Mage::helper('paymentmail')->__('Test Question') ?>" value="" class="input-text" type="text" />
                    </div>
                </div>
                <div class="field">
                    <label for="test_answer" ><?php echo Mage::helper('paymentmail')->__('Test Answer') ?></label>
                    <div class="input-box">
                        <input name="test_answer" id="test_answer" title="<?php echo Mage::helper('paymentmail')->__('Test Answer') ?>" value="" class="input-text" type="text" />
                    </div>
                </div>
           </li>
        </ul>
    </div>
    <div class="buttons-set">
        <p class="required"><?php echo Mage::helper('paymentmail')->__('The fields marked with * are mandatory') ?></p>
        <p><strong>Please be aware we collect The IP and ISP for legal and security purposes when submitting a request.</strong></p>
             <input name="form_type" id="form_type" value="moneygram"  type="hidden" /> 
        <button type="submit" title="<?php echo Mage::helper('paymentmail')->__('Submit') ?>" class="button"><span><span><?php echo Mage::helper('paymentmail')->__('Submit') ?></span></span></button>
    </div>
</form>
<script type="text/javascript">
//<![CDATA[
    var contactForm = new VarienForm('paymentmailForm', true);
//]]>
</script>


